AATMC SESSION #7 CLAIMS OPERATIONS

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2 AATMC SESSION #7 CLAIMS OPERATIONS Session Presenter: Elizabeth Grafton Claims Director

3 Upon completion of this session, participants will be exposed to: Objective Content #1 Contracting Provisions as they apply to Claims #2 Claims processing date range start/end #3 Case processing phases Evaluation, Pre, Transplant, Post #4 Claims Repricing Examples #5 Special Provisions - i.e.: VAD

4 # Slides Content 5 Slides Contract Provisions Definitions 2 Slides Start Dates Phases of Contract 4 Slides Evaluation 6 Slides Pre Transplant VAD Provision 5 Slides Transplant Episode 1 Slide Post Transplant 1 Slide Additional Networks

5 CONTRACT TERM Case Rate Dollar Amount Case Rate Inclusion/Exclusion (i.e., what is included in the case rate) Type of Inlier Days (e.g., consecutive, ending on discharge, etc) BMT Registry Search fees Organ Acquisition Charge Organ Acquisition In or Out of Case Rate Lesser of (aka minimum discount) Number of Inlier Days Outlier Per Diems Blood Products IVIG High Dollar Medications BMT Harvesting Charges/Preparative Therapy Stop Loss (aka maximum achievable discount, floor) Readmission Death During Case Rate CONTRACT TERM Re-transplant Potential Living Donor Testing Pre/Post Transplant Discount Pre/Post Timeframe (e.g., starts at eval, ends 365 after discharge) Implantable Devices (e.g., VADS) Payment Terms (e.g., amount of time for prompt pay) Rate Modification (e.g., inflation clause) Non-Transplant Related Care Discharge Medication Housing Home Health Care Non-campus Dialysis Rehabilitation Outpatient DME Transportation

6 What does this mean? Can a provider bill whatever they feel when the contract states a claim will be paid with a % off billed charges? NO! There is a charge master in effect for periods of time to support the charge by the provider. Billed charges defined: The standard fee the Provider customarily charges for a specified health care service, which is in effect at the time such service is provided, regardless of Payor This does not mean that the standard fee is the same for a provider in California versus a provider in Wisconsin.

7 Provisions Per Diems Per Diems in this phase are rare but an added benefit to the health plan Special VAD pricing Keep in mind these provisions are specific to the device itself

8 1 st Date of Evaluation Day of Referral by Health Plan to Network Date of Health Plan Signature on Patient Specific Network Contract 1 st Day of Inpatient Admit (Usually an urgent admit situation or late notice to Health Plan of Transplant Patient)

9 Phase 1 Evaluation Phase 2 Pre Phase 3 Transplant Phase 4 - Post In most instances are processed using our percentage agreement Each phase ends when the next begins

10 Kidney $16,725 Liver $29,650 Heart $26,215 Kidney/Pancreas $17,000 Pancreas $16,828 Lung (Single) $22,896 Lung (Double) $36,175 Autologous BMT $22,667 Related Donor, Allo BMT $23,468 Unrelated Donor, Allo BMT $23,468

11 Full physical exam Nutritional evaluation Psychosocial evaluation Blood tests Tissue typing X-rays, MRI, CAT Scan Cardiac functions and tests Dental exam Gynecological exam

12 Heart patient with evaluation for transplant. Evaluation spanning a 4 day period Hospital & Professional Claims 15 total claims 18 different diagnosis codes Charges in-line with expectations $26,912 $22,965 $218 $103 $99 $162 $22 $488 $488 $29 $175 $1,000 $500 $313 $175 $175

13 Hospital Claims include: UNS HEART FAILURE CONGESTIVE HEART FAILURE UNSPEC AC/CHRONIC SYSTOLIC HEART FAILURE PAROXYSMAL VENTRICULAR TACHYCARDIA V72.81 Pre Op Cardiovascular Exam Other pulmonary insufficiency Professional Claims include: UNS SECONDARY CARDIOMYOPATHY CONGESTIVE HEART FAILURE UNSPEC OTHER CARDIAC DYSRHYTHMIAS V72.81 Pre Op Cardiovascular Exam OTHER CARDIAC DYSRHYTHMIAS TACHYCARDIA UNSPECIFIED V42.1 Heart Replaced by Transplant Procedure code = Office Consultation low complexity

14 Patient is home being seen by local physician Periodic appointments with network provider to ensure the patient is in compliance with treatment plan and is still a candidate Office visits Labs Patient is having complications/nearing transplant Patient will likely be having complications due to disease and deteriorating Inpatient Stays Labs Surgeries

15 Contract Provisions Considered Pre/Post Transplant Discount Start date of Contract Extra consideration (VAD) VAD paid at invoice cost Let s take a look at a claim!

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19 Invoice Cost of LVAD $ $1, $1, $ 75, $78, Billed charge = $160, Invoice cost = $ 78, Savings = $ 81,609.19

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21 Kidney $262,900 Liver $577,100 Heart $997,700 Kidney/Pancreas $474,700 Pancreas $289,400 Lung (Single) $561,200 Lung (Double) $797,300 Autologous BMT $363,800 Related Donor, Allo BMT $805,400 Unrelated Donor, Allo BMT $805,400

22 Inlier Days The number of days the contract has allotted for the case rate. Also known as bank of days. Organ Acquisition Are the Organ acquisition charges included in the case rate or are the charges addressed singularly in the contract verbiage. Lessor of Language If the total charges for the Transplant episode come in under the allowed case rate amount, then lessor of may apply. Case Rate The applicable set amount of dollars allowed for the Transplant episode itself with in a specific date range. Stop Loss Provision The least amount the facility will accept for a Transplant episode Outlier Per Diems The charge per day for any inpatient days that fall outside of the case rate.

23 Inlier Days Organ Acquisition Lesser of Language Case Rate Stop Loss Provision Outlier Per Diems 16 Inlier Days Included in case rate Yes, 80% of Billed Charges $143, % of billed charges Outlier Per Diem= $ Med/Surge 3, ICU/CCU

24 Billed Charges Hospital $814, Billed Charges Professional + $ 30, Total Billed Charges $844, Total Billed Charges $844, Payable $422, Savings $422, Or 50%!!

25 Are there any special provisions we need to be aware of? In this contract the Organ Acquisition charge is included in the Case Rate so we do not have to separate that line item from the total charges. Does this contract fall to the Lessor Of provision? No. Why? If you take the total billed charges $844, x 80% = $675, The total is much higher than the allowed case rate, so we can tell at a glance that Lessor Of will not apply in this case. Does this contract fall to the Case Rate provision? No. Why? Because we can see that if you multiply the total billed charges $844, x 50% (the Stop Loss) = $ The Case Rate for this Transplant is $143, Does this contract fall to the Stop Loss provision? Yes. The charges for this patient will fall to Stop Loss based on reviewing all provisions and doing the math in order to make the correct determination.

26 Patient is discharged from the inpatient stay Regular weekly visits with Network providers for 1 3 months Common for monthly visits to continue for first year Increased usage of referring physician follow up Office visits Labs Transplant center will follow patient for life Yearly visit Office visits Labs Not covered by transplant network contract Ends one year post Immunosuppressant's Covered by patient s drug benefit

27 VAD Maintenance Home Monitoring Services Contracts with Alere and Continuum! Bariatric Services Access to reduce costs Proton Therapy 10 fully operational Proton Therapy centers and another 8 under construction.

28 1) Ask Questions & Seek Clarification 2) Complete The Post Test (Link in This Course s Section of Website) 3) Plan The Time For Your Next AATMC Session 4) Attend a Medical Roundtable (At Least Two Required)

29 Presenter Title Ext. Elizabeth Grafton Claims Director 225